STUDY

Factors Contributing to Incomplete Excision

of Nonmelanoma Skin Cancer by Australian
General Practitioners
Craig Hansen, PhD; David Wilkinson, DSc; Mary Hansen, BSc; H. Peter Soyer, MD, FACD

Objective: To study rates of incomplete excision of basal

(BCC) and squamous (SCC) cell cancer by Australian general practitioners with a special interest.
Design: Records review.
Setting: A network of 15 primary care skin cancer clin-

ics across Australia.

Participants: Fifty-seven physicians performing excisions of 9417 BCCs and SCCs in a single network of 15
primary care skin cancer clinics across Australia between 2005 and 2007.
Main Outcome Measures: Rates of incomplete excision according to physician, clinic, anatomic location of
the lesion, and whether a previous biopsy had been
performed.
Results: Four hundred forty-three of 6881 BCCs (6.4%)

and 159 of 2536 SCCs (6.3%) were excised incompletely.

Incomplete BCC and SCC excisions were more frequent
on the head and neck (282 of 2872 excisions [9.8%] and

Author Affiliations: School of

Medicine, University of
Queensland (Drs Hansen and
Wilkinson and Ms Hansen),
and Dermatology Research
Centre and School of Medicine,
University of Queensland, and
Princess Alexandra Hospital
(Dr Soyer), Brisbane,
Queensland, Australia.

97 of 861 [11.3%], respectively) than elsewhere. Ears (74

of 388 excisions [19.1%]) and nose (78 of 546 [14.3%])
had the highest rates of incompletely excised BCCs, and
ears (26 of 144 excisions [18.1%]) and forehead (20 of 157
[12.7%]) had the highest rates of incompletely excised
SCCs. Of all BCC excisions, 67.3% were once-off excisions with no previous biopsy, and these excisions were
more likely to be incomplete (odds ratio, 1.73; 95% confidence interval, 1.36-2.20) than those with a previous biopsy. There was, however, substantial variation in frequency of incomplete excision between clinics for BCC
(ranging from 3.3% to 24.7%) and SCC (ranging from 0%
to 17.2%) and between physicians within clinics (BCC ranging from 0% to 31.1%, and SCC ranging from 0% to 23.5%).
Conclusions: Overall frequency of incomplete excision is low and similar to that in other reports. However, high frequency in high-risk sites, low rates of previous biopsy, and substantial variation in performance
between physicians and clinics suggests there is significant opportunity to further improve health outcomes.

Arch Dermatol. 2009;145(11):1253-1260

KIN CANCER IS THE MOST COM1

mon cancer in Australia.

Nonmelanoma skin cancer
(NMSC) is the most commonly diagnosed cancer in
Australia,2 with basal cell carcinoma (BCC)
accounting for approximately 70% to 80%
of malignant neoplasms and squamous cell
carcinoma (SCC) accounting for approximately 15% to 30%.3,4 Recent surveys in
Australia have shown that the incidence
of BCC and SCC is on the rise3; despite the
low mortality rate associated with these
cancers,5 NMSC is the most costly cancer
to treat in Australia, amounting to $264
million for the year 2001.6 Every year in
Australia more than 1 million patient consultations for skin cancer are performed
by general practitioners (GPs).5
A recent study reported that Australian
GPs perform more excisions on NMSC than
specialists, and the excision rate has in-

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1253

creased significantly more among the GPs.7

This increase is largely due to GPs with a
special interest (GPwSIs) becoming an established feature of the primary health care
system, particularly in Australia and the
United Kingdom. In the United Kingdom,
GPwSIs have a specific role in the area of
dermatology and skin cancer. Whereas in
the United Kingdom GPwSIs are integrated into local care networks and are required to follow guidance provided by the
National Institutes of Clinical Excellence,
in Australia there is no such integration or
guidance, and skin cancer clinics typically
work in relative isolation.
Studies have shown that the rate of incomplete excision for NMSC is higher
among GPs than specialist consultants.8,9
Therefore, concerns have been raised by
specialist consultants (eg, dermatologists
and plastic surgeons) about the quality of
care in these skin cancer clinics largely ser-

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viced by GPwSIs; however, few data are available to validate these concerns. For example, although a handful of
retrospective clinical audits have been carried out on the
rate of incomplete excisions of NMSC, the sample size
within these studies has been small.8,10-12
It is vital to critically appraise the quality of care provided by novel models of health service as they emerge.
Therefore, the purpose of our study was 2-fold. First, we
sought to determine the overall and anatomic site
specific rates of incomplete excision of BCCs and SCCs
among a single corporate network of skin cancer clinics. Second, we sought to determine how much variation in this measure there was between clinics and between physicians.
METHODS

of the clinical visit, patient sex, patient age, patient postal code,
physician ID, clinic ID, and clinic postal code.
The electronic pathology reports came in the form of unstructured text, and several steps were carried out to establish
categories for the final analyses. First, the text for each lesion
within each report was extracted to create an individual record for each lesion. Then various categories were established
by scanning the text within each record for terminology pertaining to the type of lesion (eg, final diagnosis), the type of
procedure performed (eg, punch biopsy or excision), the anatomic site and orientation, and surgical margins. To identify
the lesions that had a follow-up procedure (eg, final excision
after an initial biopsy), we matched lesion reports by patient
(including age and sex), diagnosis, anatomic site and orientation, type of procedure, and dates of visits. All BCC and SCC
excisions were then selected for the final analyses. This research was approved by the University of Queensland Behavioral and Social Sciences Ethical Review Committee.

SETTING

DATA ANALYSIS

The clinics studied composed a single network of skin cancer

clinics staffed by GPwSIs across most states in Australia. In this
study, GPwSIs was defined as GPs who have chosen to spend
all or most of their time working in primary care skin cancer.
Their training consisted of a series of 10 modules that covered
the basics of diagnosis and management of skin cancers, policies and procedures in the clinics, and how to bill correctly.
The training was not developed by any academic institution but
rather by a registered training organization with input from
some experienced physicians in the clinics. All certification
was internal to the clinics.
In contrast, in Australia the Dermatology College Training
Programme (4 years, full time) is fully accredited by the Australian Medical Council. The program, outlined in detail in the
Colleges Training Program Handbook, is very well structured
and comprehensive, and malignant neoplasms of the skin represent an integral part. At the end of the training period, trainees are competent to accurately assess and diagnose all skin lesions with which they may be confronted in practice. They have
gained experience in and become competent in dermoscopy,
and they are competent in the performance of basic procedures to deal with the skin lesions encountered.
In Australia there are 4 or 5 relatively large chains of skin
cancer clinics, with the largest having about 30 clinics. The chain
we studied was the third largest at the time of the study.
Although owned by a single corporate structure, the clinics
within the chain we studied were typically widely dispersed and
the staff working within them had limited contact, other than
by e-mail, telephone, and an annual meeting. There were no corporate instructions on how to deliver services or what treatments to use, and training was provided by informal orientation as well as a more formal in-house training program.
Physicians worked as independent subcontractors in the clinics
and, although there was no requirement to use a specific pathology provider, most physicians used a service that was partly owned
by the company that owned the clinics. Since our data collection was completed, the clinics and pathology service have been
sold to a larger national health care company.

DATA COLLECTION
We obtained 31 117 de-identified skin pathology reports for
the period February 25, 2005, to March 30, 2007. Each pathology report included detailed information for each lesion in the
form of statements of clinical, macroscopic, and microscopic
findings and conclusion. Other information included the date

We report the proportions of incomplete margins for BCC and

SCC separately. They are first reported as percentages for each
specific anatomic site and then as percentages within the aggregated anatomic sites of head and neck, trunk, arms,
and legs. We then assessed whether patient age, patient sex,
anatomic site, and type of excision (once-off vs final excision
after biopsy) were predictors of incomplete margins. Odds ratios and 95% confidence intervals (CIs) for an incomplete margin were calculated by means of a generalized estimating equation. The generalized estimating equation was used to control
for the repeated data (eg, multiple lesions per patient) during
analysis with PROC GENMOD in SAS Version 9.1 (SAS Institute Inc, Cary, North Carolina) with an exchangeable correlation matrix. The models included incomplete margins (yes/
no) as the dichotomous dependent variable and patient sex,
grouped patient age based on quartiles (50, 51-60, 61-70, and
70 years), anatomic site, and type of excision (initial vs followup) as the independent variables.
To assess for any variation across clinics, further models included an indicator variable for clinic. Arbitrarily, the clinic with
the most excisions performed was chosen as the reference category in the models. In addition, the clinic and patient postal
codes were linked to an index of socioeconomic status created
by the Australian Bureau of Statistics at a postal code level.13
This index was then grouped into quartiles and also entered
into the regression models. However, when patient and clinic
socioeconomic status was included in the regression model, neither was associated with incomplete margins of BCC and SCC,
and therefore they were not included in the final models.
RESULTS

BASAL CELL CARCINOMA

We identified 7058 BCC excisions. In 177 (2.5%) there
was no report on margin completeness, leaving 6881 BCC
excisions for analysis. Of these, 2248 (32.7%) were the
final excision that followed an initial biopsy, and 4633
(67.3%) were once-off excisions that did not have a previous biopsy. The 6881 BCCs came from 4428 patients
(2809 of them male [63.4%]) examined by 52 different
physicians from 15 different clinics. Mean patient age was
60 years (range, 11-98 years), and females were 2 years
younger than males (P.001). Overall (Table 1), 67.7%

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Table 1. Anatomic Distribution of Excised BCC Lesions and Proportion of Incomplete Excisions
Total

Female

Male

Location

No.

Incomplete Margins,
No. (%)

No.

Incomplete Margins,
No. (%)

No.

Incomplete Margins,
No. (%)

Head and neck

Ears
Eyes/brow
Cheeks/mouth/chin
Nose
Forehead
Scalp
Neck
Trunk
Back
Front
Shoulders
Buttocks/genitals
Legs
Legs (nonspecific)
Thighs
Lower legs
Feet
Arms
Arms (nonspecific)
Upper arms
Lower arms
Hands
Not stated
Total

2872
388
270
566
546
554
103
445
2451
1265
619
548
19
541
189
101
219
32
1016
385
169
391
71
1
6881

282 (9.8)
74 (19.1)
22 (8.1)
52 (9.2)
78 (14.3)
38 (6.9)
4 (3.9)
14 (3.2)
104 (4.2)
51 (4.0)
31 (5.0)
22 (4.0)
0
30 (5.6)
8 (4.2)
4 (4.0)
15 (6.9)
3 (9.4)
27 (2.7)
8 (2.1)
5 (3.0)
12 (3.1)
2 (2.8)
NA
443 (6.4)

948
60
80
196
245
189
35
143
741
359
192
187
3
183
72
34
67
10
354
149
67
109
29
0
2226

100 (10.6)
11 (18.3)
5 (6.3)
20 (10.2)
42 (17.1)
14 (7.4)
2 (5.7)
6 (4.2)
38 (5.1)
18 (5.0)
12 (6.3)
8 (4.3)
0
16 (8.7)
6 (8.3)
1 (2.9)
6 (9.0)
3 (30.0)
12 (3.4)
5 (3.4)
3 (4.5)
4 (3.7)
0
NA
166 (7.5)

1924
328
190
370
301
365
68
302
1710
906
427
361
16
358
117
67
152
22
662
236
102
282
42
1
4655

182 (9.5)
63 (19.2)
17 (9.0)
32 (8.7)
36 (12.0)
24 (6.6)
2 (2.9)
8 (2.7)
66 (3.9)
33 (3.6)
19 (4.5)
14 (3.9)
0
14 (3.9)
2 (1.7)
3 (4.5)
9 (5.9)
0
15 (2.3)
3 (1.3)
2 (2.0)
8 (2.8)
2 (4.8)
NA
277 (6.0)

Abbreviations: BCC, basal cell carcinoma; NA, not applicable.

of the BCCs were excised from men, with most from the
head and neck (41.7%) followed by the trunk (35.6%).
In all, 443 of 6881 BCC excisions were incomplete
(6.4%), with the head and neck having a significantly larger
percentage incomplete (282 of 2872 excisions [9.8%]) than
other anatomic areas. More specifically (Table 1), the ears
and nose had the highest rate of incomplete BCC excisions (74 of 388 [19.1%]).
After controlling for all other factors, results from the
regression analyses (Table 2) showed that women had a
28% (odds ratio [OR], 1.28; 95% CI, 1.03-1.59) increased
risk of having an incomplete excision compared with males,
patients older than 70 years had a 52% (OR, 1.52; 95% CI,
1.13-2.04) increased risk of having an incomplete excision compared with those 50 years or younger, and, overall, if the excision was not preceded by a biopsy, there was
a 73% (OR, 1.73; 95% CI, 1.36-2.20) increased risk that it
would be incomplete. When stratified by anatomic site,
patient sex was no longer significantly associated with incomplete margins. In other stratified analyses, patient age
was significant only among the head and neck excisions
and, if the excision was performed on the arms, the onceoff excisions with no previous biopsy were 3 times more
likely to be incomplete than were final excisions that had
a previous biopsy (OR, 3.13; 95% CI, 1.07-9.16).
SQUAMOUS CELL CARCINOMA
There were 2639 SCC excisions identified, of which 103
(3.9%) had no report on margin completeness, leaving
2536 SCC excisions for analysis. Of these, 545 (21.5%)

were the final excision that followed an initial biopsy, and

1991 (78.5%) were once-off excisions that did not have
a previous biopsy. These lesions came from 1881 patients (1209 of them male [64.3%]) treated by 55 different physicians from 15 different clinics. Mean patient age
was 65 years (range, 23-95 years), and females were 3
years older than males (P .001).
Table 3 shows the anatomic distribution of the SCC
excisions; 34.0% were from the head and neck, 34.0% from
the arms, and 21.6% from the legs. This is much different
from the distribution of BCCs (Table 1). The proportion
of SCC excisions reported as incomplete was 6.3% (the same
as for BCCs), and the proportion was highest for the head
and neck (11%). Specifically, ears and eyes/brow had the
highest rates of incomplete SCC excisions (Table 3).
In contrast to BCC excisions, results from the regression model showed that, except for the head and neck site,
which was almost 3 times more likely than the trunk to
have incomplete SCC excisions (OR, 2.89; 95% CI, 1.525.51), none of the other variables studied were associated
with incomplete margins among SCC excisions (Table 2).
VARIATION ACROSS CLINICS AND PHYSICIANS
Figure 1 shows the proportion of incomplete exci-

sions across the 15 clinics ordered by the total number

of excisions performed at each clinic. There was considerable variation across the 15 clinics (3.3%-24.7% for
BCCs and 0%-17.2% for SCCs). The same clinic (clinic
F) was responsible for the highest rate of incomplete BCC
and SCC excisions, and in the regression model (results

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Table 2. Odd Ratios (95% CIs) for Incomplete Excisions of BCC and SCC
Anatomic Site
Variables in Model

All

Head and Neck

Trunk

Legs

Arms

BCC Excisions
Sex
Male
Female
Age, y
50
51-60
61-70
70
Type of excision
Final (previous biopsy)
Once-off (no previous biopsy)
Anatomic site
Trunk
Arms
Legs
Head and neck

1 [Reference]
1.28 (1.03-1.59) a

1 [Reference]
1.12 (0.85-1.48)

1 [Reference]
1.40 (0.91-2.14)

1 [Reference]
1.86 (0.78-4.46)

1 [Reference]
1.50 (0.67-3.32)

1 [Reference]
1.15 (0.84-1.56)
1.19 (0.87-1.62)
1.52 (1.13-2.04) b

1 [Reference]
1.39 (0.92-2.10)
1.33 (0.88-2.03)
1.75 (1.18-2.59) b

1 [Reference]
0.86 (0.49-1.52)
1.35 (0.78-2.32)
1.19 (0.65-2.17)

1 [Reference]
0.31 (0.09-1.08)
0.68 (0.19-2.46)
0.99 (0.33-2.96)

1 [Reference]
1.55 (0.59-4.07)
0.43 (0.11-1.70)
1.02 (0.32-3.22)

1 [Reference]
1.73 (1.36-2.20) c

1 [Reference]
1.60 (1.17-2.19) b

1 [Reference]
1.65 (1.03-2.64) a

1 [Reference]
1.07 (0.12-9.21)

1 [Reference]
3.13 (1.07-9.16) a

1 [Reference]
0.59 (0.37-0.93)
1.17 (0.73-1.88)
2.30 (1.81-2.94) c

NA
NA
NA
NA

NA
NA
NA
NA

NA
NA
NA
NA

NA
NA
NA
NA

SCC Excisions
Sex
Male
Female
Age, y
50
51-60
61-70
70
Type of excision
Final (previous biopsy)
Once-off (no previous biopsy)
Anatomic site
Trunk
Arms
Legs
Head and neck

1 [Reference]
0.82 (0.56-1.18)

1 [Reference]
0.66 (0.39-1.13)

1 [Reference]
1.03 (0.27-3.94)

1 [Reference]
1.09 (0.51-2.31)

1 [Reference]
0.77 (0.33-1.79)

1 [Reference]
1.32 (0.75-2.44)
1.35 (0.74-2.47)
1.32 (0.73-2.38)

1 [Reference]
1.32 (0.58-2.98)
1.41 (0.65-3.05)
1.32 (0.62-2.82)

1 [Reference]
0.19 (0.02-1.81)
1.22 (0.34-4.29)
0.56 (0.13-2.32)

1 [Reference]
0.79 (0.18-3.51)
0.38 (0.08-1.78)
0.61 (0.15-2.39)

1 [Reference]
2.15 (0.44-10.42)
1.98 (0.41-9.55)
2.75 (0.59-12.66)

1 [Reference]
1.01 (0.67-1.51)

1 [Reference]
1.19 (0.70-2.01)

1 [Reference]
0.75 (0.21-2.70)

1 [Reference]
0.64 (0.27-1.46)

1 [Reference]
0.82 (0.32-2.10)

1 [Reference]
0.73 (0.35-1.49)
1.09 (0.52-2.27)
2.89 (1.52-5.51) b

NA
NA
NA
NA

NA
NA
NA
NA

NA
NA
NA
NA

NA
NA
NA
NA

Abbreviations: BCC, basal cell carcinoma; CIs, confidence intervals; NA, not applicable; SCC, squamous cell carcinoma.
a P .05.
b P .01.
c P .001.

not shown) this clinic was 8 times more likely than the
referent clinic to have incomplete margins.
Figure 2 and Figure 3 show the proportion of incomplete margins for BCC and SCC, respectively, per physician within each clinic. There was considerable variation in the rate of incomplete margins for BCC (ranging
from 0% to 31.3%) and SCC (ranging from 0% to 23.5%)
for physicians within clinics. This variation was not accounted for by differences in the number of tumors excised, or the proportion excised from different anatomic sites. These data demonstrate clearly that there was
a considerable problem with physician 2 in clinic F and
physician 5 in clinic L, as both had among the highest
rates of incomplete BCC and SCC margins.
COMMENT

Our study has 2 key messages. The first relates to the rate
of incomplete excision of BCCs and SCCs by GPwSIs. This
is by far the largest series of cases we could find in the literature, and the overall rate of incomplete margins within

our study (6%) is similar to, or lower than, that reported

in other studies. For example, a recent study showed an
overall rate of 14% incomplete margins for BCC and SCC
excisions combined. Within that study, the rate was 26%
among GPs, 10% among consultants (eg, general surgeons, plastic surgeons, and dermatologists), and 10%
among registrars.8 A similar study also reported an overall rate of 14% incomplete margins for both BCCs and SCCs
combined, and the rate among GPs was 16%; consultants, 12%; and registrars, 8%.9 Studies focusing on incomplete BCC excisions among plastic surgeons have reported rates ranging from 2% to 11.2%,10,11,14-17 whereas a
rate of 10.3% has been reported among dermatologists.18
Studies focusing on incomplete SCC excisions have reported rates of around 6% among specialist consultants.4,19 It should be noted, however, that high rates of incomplete excisions by consultant surgeons may largely be
due to the selection of more difficult cases.10
As expected, we also show that a much higher rate of
incomplete excision occurs in tumors in high-risk sites
such as those around the face, and this is in agreement

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Table 3. Anatomic Distribution of Excised SCC Lesions and Proportion of Incomplete Excisions
Total

Female

Male

Location

No.

Incomplete Margins,
No. (%)

No.

Incomplete Margins,
No. (%)

No.

Incomplete Margins,
No. (%)

Head and neck

Ears
Eyes/brow
Cheeks/mouth/chin
Nose
Forehead
Scalp
Neck
Trunk
Back
Front
Shoulders
Buttocks/genitals
Legs
Legs (nonspecific)
Thighs
Lower legs
Feet
Arms
Arms (nonspecific)
Upper arms
Lower arms
Hands
Total

861
144
51
248
80
157
58
123
265
91
120
52
2
548
231
72
227
18
862
138
28
391
305
2536

97 (11.3)
26 (18.1)
6 (11.8)
25 (10.1)
8 (10.0)
20 (12.7)
5 (8.6)
7 (5.7)
11 (4.2)
1 (1.1)
7 (5.8)
3 (5.8)
0
25 (4.6)
8 (3.5)
5 (6.9)
10 (4.4)
2 (11.1)
26 (3.0)
2 (1.5)
2 (7.1)
11 (2.8)
11 (3.6)
159 (6.3)

223
9
14
88
38
30
3
41
66
20
33
13
0
230
102
17
100
11
337
53
14
132
138
856

19 (8.5)
2 (22.2)
0
8 (9.1)
3 (7.9)
10 (33.3)
1 (33.3)
2 (4.9)
3 (4.6)
1 (5.0)
2 (6.1)
0
NA
12 (5.2)
6 (5.9)
0
6 (6.0)
0
9 (2.7)
1 (1.9)
1 (7.1)
5 (3.8)
2 (1.4)
43 (5.0)

638
135
37
160
42
127
55
82
199
71
87
39
2
318
129
55
127
7
525
85
14
259
167
1680

78 (12.2)
24 (17.8)
6 (16.2)
17 (10.6)
5 (11.9)
17 (13.4)
4 (7.3)
5 (6.1)
8 (4.0)
0
5 (5.8)
3 (7.7)
0
13 (4.1)
2 (1.6)
5 (9.1)
4 (3.1)
2 (28.6)
17 (3.2)
1 (1.2)
1 (7.1)
6 (2.3)
9 (5.4)
116 (6.9)

Abbreviations: NA, not applicable; SCC, squamous cell carcinoma.

30

All
BCC
SCC

% Incomplete

25
20
15
10
5
0
Excisions, No.
Physicians, No.
Clinic

31
1
A

61
1
B

145
7
C

166
3
D

246
4
E

300
2
F

309
4
G

325
3
H

468
4
I

646
3
J

768
3
K

879
8
L

998
3
M

1874
8
N

2201
3
O

Figure 1. Proportion of incomplete basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) excisions across the 15 clinics by total number of excisions
performed.

with the literature.4,8,14,18-21 The current study showed that

for BCCs the highest rates of incomplete excisions were
on the ears (19%) and nose (14%) areas. Similarly, the
highest rates of incomplete excisions for SCCs were also
on the ears (18%), with the rates for eyes/brow, cheek/
mouth/chin, nose, and forehead ranging between 10% and
13%. This is because, largely for cosmetic and functional reasons, there is a tendency to use narrower margins in the head and neck regions, specifically the cheek,
nose, forehead, and ear.21
In the current study, female patients also had a small
increased risk (28%) of an incomplete excision, but only

for BCCs, whereas other studies have failed to find that

patient sex is a predictor of incomplete excisions for
BCCs18 and SCCs.4,19 After controlling for age, duration
of tumor, anatomic site, histologic subtype, horizontal
diameter of the tumor, and ulceration, Takenouchi and
colleagues20 reported that BCCs in males have a propensity for deeper invasion than those in females; however,
that does not explain why in our study females with BCCs
had a higher risk of incomplete margins.
After controlling for all other factors, our results also
showed that the risk of incomplete BCC excisions was significantly higher among patients older than 70 years (when

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40

1
1
1
16
54
73

39
44
48
131

16
54
90
160

42
148
190

3
50
172
225

3
26
73
131
233

3
5
160
181
349

4
47
454
505

60
114
364
538

1 2 3 4 5
C

1 2 3
D

1 2 3
E

1 2
F

1 2 3
H

1 2 3 4
G

1 2 3 4
I

1 2 3
J

1 2 3
K

22 55

35

% Incomplete

30

4
8
17
26
36
101
415
607

59
139
584
782

14
16
74
82
104
350
591
1231

122
817
841
1780

1 2 3
M

1 2 3 4 5 6 7
N

1 2 3
O

25
20
15
10
5
0

Physician
Clinic

1
A

1
B

1 2 3 4 5 6 7
L

Physicians Grouped by Clinic

Figure 2. Proportion of incomplete basal cell carcinoma excisions by physician grouped by clinic, ordered by the total number of basal cell carcinoma excisions
performed. At the top are the number of excisions performed per physician and clinic (the numbers going down match the physicians going left to right within
each clinic).

30

5
8
22
35

1
1
2
4
4
18
42
72

19
20
37
76

1
5
17
63
86

3
22
75
100

12
98
110

2
36
81
119

7
16
118
141

19
40
157
216

11
29
190
230

2
5
5
7
11
33
41
168
272

25
149
247
421

1
B

1
A

1 3 2
D

3 2 6 1 7 4 5
C

3 2 4
G

4 1 2 3
E

1 2 3
H

1 2
F

2 3 4
I

1 2 3
J

1 2 3
M

1 2 3
K

8 4 2 1 3 5 6 7
L

1 3 2
O

25

% Incomplete

20

1
4
7
17
28
42
190
354
643

15

10

0
Physician
Clinic

8 1 2 3 4 5 6 7
N

Physicians Grouped by Clinic

Figure 3. Proportion of incomplete squamous cell carcinoma excisions by physician grouped by clinic, ordered by the total number of squamous cell carcinoma
excisions performed. At the top are the number of excisions performed per physician and clinic (the numbers going down match the physicians going left to right
within each clinic). The physician identification number matches up with the physician identification number assigned in Figure 2.

compared with patients 50 years), but this was not the

case for SCC excisions. In the few studies that have investigated various predictors of incomplete margins for
BCCs, mixed results have been reported for age,11,18 whereas
other studies, similar to ours, have found that age is not a
significant predictor of incomplete margins for SCC.4,19
When the analyses were stratified by anatomic site, the
increased risk of incomplete excision among elderly patients occurred only in the head and neck area. Although
BCC lesions may be more prevalent among the elderly and
this may vary by subtype,22 it does not explain the higher
rate of incomplete excisions within this age group, particularly on the head and neck areas. However, this finding could be attributed to a longer time for cumulative sun
damage and tumor growth among the elderly and also may
be due to lack of medical attention.22 Hence, there is a like-

lihood that larger BCC lesions are found among the elderly and, for cosmetic reasons, lesions on the head and
neck area are more difficult to excise completely. For example, Bhatti and colleagues8 found that the larger the lesion, the higher the rate of having an incomplete margin,
many of which were found in the inner canthus and nasal bridge area. Furthermore, BCCs and SCCs can invade
deeply on the facial areas and can contribute to reexcision and recurrence of lesions in these areas.14,20
We found an increased risk (73%) of an incomplete excision among BCCs without a previous biopsy compared
with excisions that had a previous biopsy of some sort (eg,
shave or punch biopsy or curettage). This is interesting
because Chiller et al23 found that preoperative curettage
decreases the frequency of incomplete margins by 26% for
BCC excisions but not for SCC excisions. This is similar

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to our finding, as we found an association only with BCC

excisions and not with SCCs. It is therefore possible that,
without a biopsy and a histopathologic diagnosis, planning for full excision is insufficient. Specifically, it may be
that the necessary margins for a particular histopathological subtype cannot be determined without a biopsy. National guidelines24 recommend biopsy in most cases of suspected BCC and also recommend wider margins for more
aggressive types of BCC.
In addition, on the basis of stratified analyses, there
was still an increased risk of an incomplete margin for
BCC excisions without a previous biopsy (compared with
excisions that had a previous biopsy) on the head and
neck, trunk, and arms, with a much higher risk (3-fold)
for the last of these. The much higher risk on the arms is
interesting; we are unable to find any reference to such
a finding in the literature, and no such association was
found for SCC in our series.
The second key message from this study is that the
services provided by GPwSIs may be highly variable in
their outcomes. Most physicians in our series had rates
of incomplete excision similar to the series average, although a small number had much higher rates. There also
was substantial variation in incomplete excision rates between and within clinics. As shown in Figures 2 and 3,
in several of the clinics this variation was due mostly to
1 or 2 physicians within each clinic. While studies have
compared the incomplete excision rates for NMSC among
different specialty professions,8,9 to our knowledge there
is no literature comparing incomplete excision rates
among GPwSIs within and across a large number of skin
cancer clinics. Although we observed substantial variation in the rates of incomplete BCC and SCC lesions between and within clinics, further research is required to
corroborate our findings.
The strengths of our data include the very large number of tumors, the substantial number of physicians and
clinics included, and the wide geographic scope. This compares with other reports published on this topic, which
typically include no more than a few hundred cases, often from a small number of clinicians.
Our data do have limitations. First, we cannot be sure
that all tumors excised by all physicians in all of these
clinics were examined by the same pathology provider,
and hence our data set may be incomplete. Although physicians have no direct financial incentive to use the same
provider, we know (from personal communications with
them) that almost all do. Also, because this was not a longitudinal study, data on subsequent excisions after the
time of data collection were not available. It also does not
capture cases of incomplete excision in which pathological margins may have been clear but subsequent clinical
tumor recurrence was not.
Second, because of the structure of the pathology reports, we were unable to reliably extract data on histopathological subtypes of BCCs and SCCs, so we were unable to explore the association between aggressive
subtypes and incomplete margins. It is therefore possible that the high rates of incomplete margins among
some physicians is due, at least in part, to their treating
larger numbers of patients with aggressive cancers and
tumors in high-risk sites (head and neck). However, we

were able to control for anatomic site and have no reason to believe that case selection occurred to any significant extent. These are primary care clinics treating an unselected and nonreferred patient population, although it
is possible that some intraclinic referral of difficult cases
occurs. Furthermore, we were unable to extract information on the lesion size, and various analyses among
different subgroups of patients and anatomic sites would
have added important information to our findings.
Finally, in our data there was no personal information
about the physicians, such as age, sex, and medical training, and it would have been interesting to include these
factors in our analyses.
In Australia there are several corporate chains of skin cancer clinics. Our study occurred in only 1 of these chains, and
generalization to the others should be done with caution.
The clinics we studied had a companywide training program
andanannualconferenceforphysicians.However,therewere
no formal treatment guidelines, no audit, and no associated
quality assurance processes, with no formal referral or specialist support networks. This contrasts with the arrangements in the United Kingdom, where the National Institutes
of Clinical Excellence have established national guidelines
and treatment pathway standards, together with formal networks and training for GPwSIs. However, despite this, recentevidencedemonstratesthatoutcomesintheUnitedKingdom are less than ideal.25
In Australia, where the burden of skin cancer is the highest in the world,3 we believe that there is a pressing need
for much more formal organization and oversight of the
management of skin cancer in primary care. Although national guidelines do exist,24 they may not be widely used.
Despite the overall incomplete rate in our study being
within a reasonable standard, the large variation among
physicians leads us to conclude that there remains a significant need for accredited training among the primary
care workforce, and, perhaps even more importantly, there
needs to be national audit and performance reporting.
Accepted for Publication: April 10, 2009.
Correspondence: Craig Hansen, PhD, School of Medicine, University of Queensland, Herston Road, Brisbane,
Queensland 4005, Australia (c.hansen@uq.edu.au).
Author Contributions: Drs Hansen and Wilkinson and
Ms Hansen had full access to all the data in the study and
take responsibility for the integrity of the data and the
accuracy of the data analysis. Study concept and design:
C. Hansen and Wilkinson. Acquisition of data: C. Hansen and Wilkinson. Analysis and interpretation of data: C.
Hansen, Wilkinson, M. Hansen, and Soyer. Drafting of
the manuscript: C. Hansen, Wilkinson, and M. Hansen.
Critical revision of the manuscript for important intellectual content: C. Hansen, Wilkinson, and Soyer. Statistical analysis: C. Hansen. Administrative, technical, and material support: M. Hansen. Study supervision: Wilkinson.
Financial Disclosure: None reported.
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